Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

Pre-cosign check: Progress note DOC-000132

Sana Pemberton · ENC-00039 · written by Dr. Keira Upfield (resident) · cosigner Dr. Wes Merriweather · status pending

Source document DOC-000132: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Sana Pemberton   MRN: MRN35397651   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Acute on chronic diastolic heart failure: continue current management.
2. Malnutrition: dietitian following.

Resident: Dr. Keira Upfield   Attending cosign: pending

Open documentation questions on this encounter (3)

Advisory only. You can cosign now; these stay with the CDI team. They come from the published criteria, not from a model.

Specificity gap Acute blood loss anaemia: Criteria support Acute blood loss anemia (D62); no corresponding diagnosis is documented.
Evidence and rule trace
Clinical judgement required Malnutrition: Clinical judgement required: Only one consensus characteristic documented; two are required.
Evidence and rule trace
Specificity gap Pressure injury: Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.
Evidence and rule trace

Only Dr. Wes Merriweather can cosign. Sign in (demo).